Episiotomy

Is it Necessary? By Lisa Hurt Kozarovich

When Missy Goodson, 34, of Louisville, Ky., had her first child in 1988, there was simply no discussion about whether she would have an episiotomy. "It was just a given; everybody got one," she says. But by the time she became pregnant earlier this year, the American College of Obstetricians and Gynecologists was recommending against the routine use of the procedure, which involves cutting the perineum area from the vagina toward the anus to enlarge the vaginal opening.

"There have been several trials over the past 20 years that have been consistent in showing there are no benefits to routine episiotomies," says Dr. Erica Eason, OB/GYN and associate professor of obstetrics and gynecology at the University of Ottawa in Ontario, Canada. "In fact, research has shown episiotomies increase the risk of infection, blood loss and pain, and do nothing to decrease urinary incontinence."

Today, episiotomies are only recommended in exceptional situations, such as if the baby is in distress, she says. Instead, women are being encouraged to massage the perineum area before labor, which helps prepare for the stretching that will occur, and to use Kegel exercises to strengthen their pelvic muscles. And their doctors are being urged to use perineum massage during labor to slowly stretch the tissue and avoid an incision.

Nonetheless, when Goodson gave birth in September she was given an episiotomy – one that was apparently unnecessary.

It's something that happens far too often, says Dr. Eason, lead author of a study appearing in the journal Obstetrics & Gynecology that found women without episiotomies fared as well, or better, than those who had the procedure.

The Facts About Episiotomy
In fact, of the 3.9 million births in 1998, 1.2 million involved episiotomies, according to the National Center for Health Statistics. While Dr. Eason estimates that episiotomies are only needed about 10 to 15 percent of the time, she says doctors perform the procedure anywhere from 10 to 90 percent of the time.

The most common episiotomy is the midline, which involves cutting straight down halfway toward the rectum. Used less often is the mediolateral, which involves cutting at a 45-degree angle from the vagina toward the leg.

Then there are natural tears, which are referred to by their severity. First-degree tears involve only the skin. A second-degree tear is similar to the midline episiotomy in that they both involve the muscle. Third- and fourth-degree tears, which involve the anal sphincter muscle, don't often occur naturally. However, research has shown it's not uncommon for a midline episiotomy to extend into a third- or fourth-degree tear -- a much more severe laceration than typically occurs without an episiotomy, Dr. Eason says.

Talk With Your Doctor
Because of the risks associated with episiotomies, women are being urged talk to their doctor about their options and the myths surrounding the procedure, such as all women with big babies must have the incision and that episiotomies help prevent neurological disorders in children by shortening the length of labor. Short- and long-term studies have proven both myths to be false, says Dr. Joshua Capel, chief of obstetrics of Yale-New Haven Hospital and professor of obstetrics, gynecology and pediatrics at Yale University.

Dr. Eason says women should ask their doctors about their rate of episiotomies, if they perform perineal massage and make sure the doctor, and those in the call group, are aware of her preference.

And it's important to be very specific about what you want and to remind the physician of that decision in the delivery room, Dr. Eason cautions. For example, though Goodson did question her OB/GYN about whether she'd need the procedure, she dropped the matter when his reply was simply, "We'll have to wait and see." Instead, Dr. Eason says, women should explain that they want to avoid a routine episiotomy, even if it means a laceration.

Avoiding Episiotomies
The best way to avoid episiotomies and tears, Drs. Eason and Capel agree, is to use lubricating jelly or warm, soapy water to massage the perineum area during labor.

Dr. Eason also suggests women perform perineal massage themselves for five to 10 minutes a day from 34 weeks to birth. Using lubrication, place your thumbs about an inch into the vagina and press the tissue down toward the rectum for two minutes. Next, use your thumbs to pull forward for about two minutes.

Researchers at Laval University in Quebec found in a study of 1,034 women, that the rate of giving birth without tearing was 61 percent higher in those who used perineal massage than those who did not.

Many doctors also recommend Kegel exercises, contracting the pelvic muscles like you would to stop the flow of urine, for about eight to 10 seconds, 50 times a day.

As for Goodson, she wasn't aware options like perineal massage and Kegel exercises could help her avoid the episiotomy that left her in pain and with stitches for six weeks.

The massage method was one 31-year-old Kim Swift was glad her providers were familiar with when she gave birth last year. Swift, a nurse from Louisville, Ky., was given a perineal massage with warm, soapy water during labor. Though she did have a slight tear, she had no pain and her two stitches were gone in less than two weeks.

But despite the evidence in favor of massage and against episiotomies, Dr. Eason says doctors too frequently cut the perineum out of false beliefs that prolonged labor is harmful, they lack experience with perineal stretching or simply because it's easier for them to repair a cut than a tear.

The best way to change the practice, she says, is for patients to educate themselves and discuss the matter with their doctor.

Want to see more?

• Avoiding Routine Interventions in Hospital Birth
• Pelvic Power: The Benefits of Kegel Exercises for Pregnancy and the Rest of Your Life
• Speedy Delivery: When Forceps Are Necessary
• Talk about it!